CMAJ Podcasts

What medical conditions and social factors increase the risk of drowning?

May 23, 2022 Canadian Medical Association Journal
CMAJ Podcasts
What medical conditions and social factors increase the risk of drowning?
Show Notes Transcript

Drowning accounts for hundreds of deaths in Canada every year. A study published in CMAJ examines how pre-existing medical conditions contribute to drowning deaths. Drs Mojola Omole and Blair Bigham speak with the study’s lead author Dr. Cody Boone about what the study’s findings mean for physicians and patients.


They then speak with Audrey Giles, a professor of human kinetics at the University of Ottawa, about the high rates of drownings experienced by Northern Indigenous communities in Canada. Professor Giles has spent decades working with people in Northern regions to adapt and customize water safety programs so that they meet communities’ specific cultural and practical needs. She discusses issues from cold water drowning to cultural safety. 



Links:

The link between medical conditions and fatal drownings in Canada: a 10-year cross-sectional analysis

Decades of water safety training culturally “irrelevant” to First Nation people

CMAJ




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Dr. Mojola Omol...: Hi, I'm Mojola Omole.

Dr. Blair Bigha...: And I'm Blair Bigham. This is the CMAJ Podcast.

Dr. Mojola Omol...: So, today's paper that we're going to be talking about is titled Evaluating the Link Between Medical Comorbidities and Fatal Drownings in Canada. It was a national 10 year total population cross-sectional analysis. The lead author's name is Dr. Cody Dunne. So, Blair, when you were reading the paper, what were some things that jumped out at you?

Dr. Blair Bigha...: Well, I guess I was just remembering my days as a lifeguard.

Dr. Mojola Omol...: Oh, you were a lifeguard.

Dr. Blair Bigha...: And I was really surprised at how many people over this study period have actually died of drowning in Canada. It was over 4,000 in about a decade.

Dr. Mojola Omol...: Yeah. And for me, I find that I did swimming when I was growing up, but I'm not a strong swimmer. And now that I have a child, drowning is actually something that's very scary to me. Because when I take my son out, we go to the pool or we go to the beach, I don't feel comfortable enough in terms of swimming. And so, just reading some of the results that they found in terms of some of the preexisting conditions that made drowning much more of a higher percentage, was quite fascinating and was a bit of a wake up call that I need to take swimming lessons or go swimming with you.

Dr. Blair Bigha...: I was shocked at how many young women drowned who had a preexisting medical condition. The increased risk of death was just shocking to me that so many people were drowning, probably because of some sort of medical condition like epilepsy.

Dr. Mojola Omol...: Yeah, for sure.

Dr. Blair Bigha...: When I was teaching swimming 20 years ago, I remember it being a bougie thing. People only had access to swimming lessons if they had a lot of money. I tended to teach swimming lessons in more wealthy areas. And then I started working for community housing, teaching swimming in the big apartment complexes in Toronto. And it was amazing how few of the kids would even have an interest in learning how to swim. And I think that that might be another thing that is really important to talk about today. Our second guest is Audrey Giles. She's going to talk to us about one community that has an increased risk of drowning, and that's the Indigenous community where drowning rates are up to 10 times as high as the national average.

Dr. Mojola Omol...: And that is actually quite fascinating, because in the States, when they look at Black Americans, they also have a higher risk of drowning. And a lot of that is due to segregation, when they were trying to desegregate and then not having pools in Black neighborhoods. And so, I think the parallel between the two countries and those two populations would be interesting to learn more about.

Dr. Blair Bigha...: Absolutely, let's jump into it.

Dr. Mojola Omol...: Let go.

Dr. Blair Bigha...: Dr. Cody Dunne is the lead author of the paper, Evaluating the Link Between Medical Comorbidities and Fatal Drownings in Canada: a national 10 year total population cross-sectional analysis. He's an emergency medicine resident in Calgary, where we reach him today. Hi Cody.

Dr. Mojola Omol...: Hi, Cody.

Dr. Cody Dunne: Hey, everyone. How are you guys doing?

Dr. Blair Bigha...: Cody, let's start with the headline. What is the risk of drowning that causes death in Canada?

Dr. Cody Dunne: Yeah. So, we're pretty fortunate in Canada, we have a lot of safeguards. A lot of public policy in place has really reduced that risk. And so, right now, there's about 500 to 600 fatal drownings per year in Canada, with about 1 to 5, 1 to 10, somewhere in that range, of non-fatal incidents causing hospitalizations each year as well.

Dr. Blair Bigha...: Now, that number sounds about the same as when I was a lifeguard 20 years ago. Do you have a sense of if drowning is becoming more or less common?

Dr. Cody Dunne: And if you look at the trends over the past several years, although there's fluctuations year to year, we've reached a pretty good steady state in Canada. And that all the safeguards that we've done have helped as much as they're going to, and now we've, I think, got to look at some creative ways of reducing that risk even further.

Dr. Blair Bigha...: Why do you think we haven't seen a lot of research on drowning to reduce that risk? Your study is one of the first ones that looked at drowning in this way.

Dr. Cody Dunne: Yeah. I think there's a couple different reasons for that. First and foremost, it's not a topic that everyone's familiar with. And if you don't have a lot of experience with it pre-medicine, then you might not get exposure to it while training in medicine and then other areas catch your interest once you're starting to research your field or your topic or your specialty. Secondly, relatively in Canada, compared to some other conditions such as cancer, such as heart disease, the risk seems relatively low. And so, you've almost, like myself, got to get dragged in from another way. You got to look at it either you were involved with it before, or something's caught your interest on a personal level and that's brought it up. So, those are two of the reasons I think that we don't see a lot of physicians or medical researchers really doing it here in Canada.

Dr. Blair Bigha...: Okay. And then what got you interested in drowning?

Dr. Cody Dunne: Yeah. Well, like yourself, I was a lifeguard. So, when I started off, did all my courses, was a pool supervisor during med school. And I think it was something that I knew and I was comfortable with. And then when I was in medicine, I made some connections across Canada. And then throughout residency, around the world, really reaching out with other researchers and it just snowballed. One thing after the other, I found a very niche area that is in desperate need of new research and new researchers interested in the field. And so, that's how I hopped on board.

Dr. Blair Bigha...: And then what inspired you to look at the comorbidities link to drowning? Really novel way of looking at things.

Dr. Cody Dunne: It actually started, we were at a conference pre-COVID over in South Africa, myself and the other co-author, Dr. Clemens, Tessa Clemens. And we were trying to brainstorm because we hadn't collaborated before on a paper. And we were trying to recognize, okay, where are the research gaps? And her interests, her PhD is in drowning epidemiology and mine's in... of course, I am a medical physician. And so, we saw a gap there and we started to link those two concepts together, and we realized that not only had this hadn't been done in Canada, which is what we thought, but there hadn't really even been a lot of research around the world in this field. So, we thought, "Hey, this is a great opportunity to explore it, and let's see what we can come up with."

Dr. Blair Bigha...: What surprised you most about the comorbidities research?

Dr. Cody Dunne: I think, even before starting, the lack of research, because it is affecting us. Drowning is one thing, but medical comorbidities are affecting everyone. Over 40% of Canadians have a chronic disease. And so, considering we all participate in water activities every day without even thinking about it, showering, bathing, a lot of us in transport drive by lakes, drive by ponds, or some of us actually cross on boats, we don't really know that risk of how are those two connecting? So, that was the first, just the under studied area was quite something. I think probably the most surprising data piece that came out of it was the decreased risk associated with respiratory disease. That wasn't something that we were intuitively expecting when we started this project. And so, coming up and seeing very low relative risks for anyone who had asthma or COPD was quite surprising.


Dr. Cody Dunne: And it was a shocker, because naturally you think, okay, these people have respiratory disease, drowning is a primarily… What’s the injuries cause?... It's through a hypoxic nature and you would think those with respiratory disease have less reserve, less physiologic reserve to be able to protect themselves from it, but the risk is lower. And so, I think it generates some hypothesis and definitely another research study in the future.

Dr. Mojola Omol…: Is it that they swim less?

Dr. Cody Dunne: Well. So, that was the first thought. But when you sit back and think about it, I don't know if that necessarily fits. Because sure, respiratory disease would, but why do people with ischemic heart disease then swim more? Or why do people with seizures disorders still swim more? And so, we thought that might have been an explanation, but I don't think we can account for such a drastic difference between the chronic medical diseases just based on that alone.

Dr. Blair Bigha...: Interesting. Cody, tell me about the higher risk groups. Who did you find is at a sort of a really high risk, people we need to keep our eye out for?

Dr. Cody Dunne: Yeah. So, in terms of medical conditions, both ischemic heart disease and seizure disorders both had an increased risk, seizure disorder being slightly higher. And then there was that very high group, the young females with seizure disorder had almost 23 times higher risk of fatal drowning. And so, those were the two high at risk. But there were also different factors or situational factors that increased people's risks. So, bathing, bathtub drowning, increased the risk as well. And that's something we're participating in every day. So, we really need to make sure that people are safe in these settings.

Dr. Blair Bigha...: The bathtub drowning really surprised me. I didn't know it was so common. Why do emergency doctors and family doctors, when they have the information from your study, what should they do with it? Should we tell people with epilepsy not to take a bath or not to swim? How big of an urgency is there for people to act on the information you've discovered?

Dr. Cody Dunne: What I think is most important is that we recognize that there's a problem here, and emergency physicians or family physicians are in the prime opportunity to do that. And we do it already with first diagnosis seizures, for example, around not driving and things like that. And just like whenever someone gets a new diagnosis, there's a spectrum of information they now have to get used to it and get prepared for. There's definitely different times and points when we have to inform them. I think the bathtub one is quite an important one. All the information on the lakes and the ponds and swimming in those settings, all that information can be pushed towards family doctors or neurologists when they're counseling at later dates. But if you think about the number of times per year you're getting in the bath and you're showering, this is something they're going to be exposed to every single day. And so, since that risk is so constant, we need to make sure they're aware of it so that they're safe and that they're not putting themselves at risk unknowingly, just like we would when we counsel around any other disease.

Dr. Blair Bigha...: Awesome, Cody. Thank you so much for taking the time to speak to us today.

Dr. Cody Dunne: Thank you guys so much for having us. I really appreciate it.

Dr. Blair Bigha...: Dr. Cody Dunne is the lead author of the paper, Evaluating the Link Between Medical Comorbidities and Fatal Drownings in Canada. He is a resident emergency physician in Calgary.

Dr. Mojola Omol...: As you mentioned off the top, the Life Saving Society and the Canadian Red Cross estimate that indigenous drowning rates are six to 10 times higher than the national average. Audrey Giles has spent many years researching this problem and working with northern Indigenous communities to improve water safety. Audrey's the full professor in the School of Human Kinetics at the University of Ottawa. Thanks for joining us today, Prof. Audrey.

Audrey Giles: Thanks so much for having me.

Dr. Mojola Omol...: So, I mentioned that there's high rates of drowning in Indigenous populations, where is this happening? Is this more of a rural issue, urban, or a combination of both?

Audrey Giles: We tend to see more Indigenous people drowning in rural and remote communities.

Dr. Mojola Omol...: And is this something that's mirrored in other racialized populations in Canada?

Audrey Giles: Yeah. It's really hard to tell because Coroner's reports in Canada do not record ethnicity. And so, the data that we have about Indigenous people drowning is actually not that strong, in terms of it's basically guesswork. So, they look at the person's last name, where they drowned, and make a guess. In some cases, I think there's a little bit more knowledge that you can gather from the news, people's families, et cetera, but the data aren't great. So, for that reason, we really have no idea about numbers for other racialized groups. We do note in the news that there are tourists who drown for sure, and also new arrivals, so new Canadians. Indeed, at the University of Ottawa where I work, we had a tragedy where three of our international students drowned in one outing.

Dr. Mojola Omol...: Oh, my gosh. That's awful.

Audrey Giles: Yeah, each trying to rescue the other.

Dr. Mojola Omol...: That's heartbreaking. You work with Indigenous populations in the Northern parts of the country, why do you think the incidence of drowning is much higher there?

Audrey Giles: That's a great question that has a complex answer, which is why I think studying it is so interesting. So, when I tell people what I do for my research, they immediately tend to trot out racist tropes about how Indigenous peoples must be drowning because they're drunk. And certainly, alcohol plays a role in drownings in any region in Canada. But I think the answer is a lot more complex when we look at the north, where drowning rates are six to 16 times the national average in any given year. So, it's really a focal point of this public health issue. And so, some of the things that contribute to it, for sure water is really cold in the North, so the stakes are higher. If you fall in, the consequences are greater than if you fell into Lake Simcoe on a beautiful day for instance. You're also a lot farther from definitive care.

So, you might be out on the land and so you're really far from the community. You'd have to get back to the community. There might have to be a MedEvac, so the MedEvac has to get there. Then you'd go maybe to the regional center. From the regional center, you might head down South. So, that definitive care, we know that the farther away you are, the less the likelihood of you surviving. And then I think poverty and education are two really key factors. We know that Indigenous communities have lower levels of educational achievement, due to horrendous experiences with colonial curricula and also lower income, again, due to rampant racism. So, anywhere you look, basically, if you take low education and you pair it with poverty, you're going to increase the risk of injury. And so, I think it's really all of those factors combined.

Another thing, too, is the availability of rescue equipment, or preventative equipment. In some towns, you literally could not buy a life jacket if you wanted to. Or it's very hard to get flares into the community because they are a restricted item on aircraft. So, there's a huge nexus of issues that really come together to make drowning a really big issue.

Dr. Mojola Omol...: And this is all on open water, or is this in the pools also?

Audrey Giles: Yeah, no, open water. So, if you look at drownings in the North, I think the history of the North there's been one…so, the Yukon, NWT, in Nunavut, there's been one swimming pool drowning. So, certainly, there'd be bathtub drownings, but most of them are happening on oceans, rivers, and lakes.

Dr. Mojola Omol...: You've been working on water safety in the northern parts of the country for decades now, how did you first get started and interested in this as a focus of your research?

Audrey Giles: Yeah. It's a bit of an interesting story and people tend not to believe me when I tell them that. The Northwest Territory, so this is pre-division with Nunavut, had a huge water safety program. So, there were about 40 locations across the north where kids took swimming lessons. And so, they're either in bodies of water, in above ground, shallow water seasonal pools that were often built in curling rinks or hockey arenas, or municipal garages over the summer. And then there were busing programs in some places that are connected to the road, so kids could go from those communities to bigger communities with pools and waterfronts. And so, I had always been interested in the North and then I had the chance to have a summer job on an island off the coast of Baffin Island. So, Cape Dorset, which now goes by Kinngait - it's a little town of 1,200 people - to run a swimming pool.

And I kept doing that as summer jobs, and really got an education, in terms of the ways in which the rest of the country ignores the North. And so, I was really interested in the ways that what I learned was right, growing up in Toronto, at beautiful facilities and how this would be life-saving information, really was not the case in the North. And that finding that some of that advice could probably kill you. And also, as a 20 year old going up North, thinking that I was an expert on drowning prevention, and then realizing that I did not have a sweet clue how to keep people safe on the Arctic ocean, was really informative to me. So, it really challenged some of my ideas. And, certainly, some parents and community members also really educated me about the ways that my view of the world was really rooted in the South.

And so, I remember, I was doing a class presentation because the whole pool was broken. Story of my life in the North. And so, we were going into classes and I was saying, "You need to stay away from the water. It's really dangerous." And the teacher took me aside and said, "Look, you can't say that. In Dene culture, the water is a giver of life and you can't talk about it as just being this dangerous thing.” And that really prompted me to think about the ways I was so rooted in my Southern understanding, because I've been taught, this is the only way to understand safety. There is safe, there is not safe, and these are the safe practices and these are the not-safe practices, without taking culture, geography, gender into account.

Dr. Mojola Omol...: So, you're a master instructor for the National Boating License Course in Canada, how does this differ up in the Northern population?

Audrey Giles: Yeah. So, the Pleasure Craft Operator Course is basically your boating driver's license, except, interestingly enough, you never actually have to go in a boat or show any competency to get this skill. So, it's an in-class or online course. It's a national certification, but it's actually not required in the Northwest Territories at Nunavut. The people in the Northwest Territories and Nunavut basically said, "This is a government intrusion into our lives. You are not going to tell the people who invented the kayak how to be safe. Back off." Also, enforcement is really tough in the North. There's not a lot of RCMP boat units going around. So, there's just this lack of fit between the course and Northerners, but what I found was that they still wanted information on how to be safe. And so

the thing with this course is that because it's a national certification, you can't take information out of it. So, I, however, could develop a Northern supplement. So, I worked with Northerners to develop a supplement to go with it. And it really snowballed from there. I now work with somebody who is involved in cold water survival. He's known as Professor Popsicle, Gordon Giesbrecht, at the University of Manitoba, who's quite famous. And because people say, "Well, we want to know how to stay safe in cold water. Well, of course, this should be part of any boating safety course." So, now, we are adapting both courses to meet Northerners’ needs.

The Pleasure Craft Operator Course has a very high language level. It is mostly offered online, which is tough for a lot of northern communities that have really poor Internet. And the language level is really off-putting for some people, especially people who have English as a second language, or maybe have struggles with literacy. And so, we're working on a plain language adaptation of it and making sure that images are of the North, and that we have Indigenous knowledge-holders contributing to the course because they're really the people who are going to keep people safe.

Dr. Mojola Omol...: What are some of your takeaways from this experience when you're talking about adaptation to setting up water safety programs in the Southern parts of the country with racialized populations, who might not have the exposure to water safety as from a young age?

Audrey Giles: I think one of the take home messages is that the same program gives different results. So, continuing to do the same thing does not make sense. And just translating signs or booklets into other languages is not enough. You really need to deeply work with communities so that you are meeting their needs. Different cultures have different belief systems around water, around drownings, and having people who understand that, being involved in designing a course, offering the course, evaluating a course is key. And that people want to be safe. Nobody wants their child to drown. Nobody wants their loved-one to drown. And so, rather than just saying, "Oh, these people aren't coming, what's wrong with them?" we need to say, “what's wrong with this course?” And that's, I think what has largely been missing, is this reflexivity around, “how do we change things so that it's successful?”

It may not be convenient. It's super not convenient to develop things for specific communities. But even in the Northwest territories, there are 11 official languages in the Northwest territories. There are really diverse cultural groups. We've got groups who live everywhere from Great Bear Lake to the Mackenzie Delta, to the high Arctic islands. And assuming that knowledge of all of these areas is going to be the same, has really been shown to be false. And so, I think if we are serious about addressing drowning in the communities that experience the highest rates of it, we need to make meaningful connections with them, build relationships, build skills, and that's bidirectional.

I get driven a little bit crazy by people who always think that, "Oh, we're training communities that experience marginalization." No, they're also training us on how not to be culturally inappropriate, how to offer programs that're going to work. And those sorts of efforts are time-intensive, they're resource-intensive. But again, I think if we're serious about making inroads with those communities, that's the approach we need to take.

Dr. Mojola Omol...: Great. Thank you. Dr. Blair Bigha...: Thank you so much for your time today.

Audrey Giles: Oh, you're welcome. Thanks for having me.

Dr. Mojola Omol...: Thank you. So, Audrey Giles is a professor at the School of Human Kinetics at the University of Ottawa.

Dr. Blair Bigha...: So, Jola, I'm a former lifeguard and ice rescue teacher, I can talk about this all day long, but I want to know what are your takeaways?

Dr. Mojola Omol...: Besides being more petrified about swimming? Because summer's coming up. I think this is, oftentimes in all of like the doctor mom groups who are always talking about swimming lessons. And I think that, even that ability to have that is a privilege, to be able to be teaching our children swimming. And that is something that probably needs to be more widespread, because it's not free. Swimming lessons aren't readily available and are free, but maybe it should be. And when you're talking about the Northern community that Audrey Giles pointed out, it's a completely different landscape. And oftentimes, public health is, what can we do that reach the most, the cheapest and effective? We have to start thinking out of the box that, for a lot of different communities, it has to look differently. Yes, that is more costly, but we have to balance that with saving lives.

Dr. Blair Bigha...: And in addition to making sure people have the opportunity to learn how to swim, for a lot of Northern communities, the risk of drowning might not just be if you know how to swim or not. If you are a great swimmer, if you're a lifeguard, and you fall into cold water, it doesn't matter how strong a swimmer you are a lot of the time, once you get cold, your ability to self rescue greatly diminishes. And so, in those cases, like Audrey was saying, it really is about having the right equipment. If you're somebody who lives out on the land, you're on ice, you're near cold water, if you don't have a survival suit and you go through, it's going to be really, really hard to survive that event.

The other thing I found fascinating, and I know we don't have time to talk too much about this but, almost every episode, Jola, we talk about Indigenous disparities and disparities between the North and the South. And I was just really inspired by Audrey's framing of how you can co-develop programs with the needs of the local community in mind and how a lot of our national standards or national licensing checklists maybe just don't really fit every situation. And it sounds like we really do need more flexibility in that regard.

Dr. Mojola Omol...: I think it ties in, when we are talking about “why do we need more diversity and inclusion in our systems?” this is why it ties in. Because then you're able to advocate for these communities. Because if I was on the swimming public health whatever, I wouldn't know any of these things about the Northern communities, but someone who's from there or someone who's worked there is able to advocate for them. So, I think this is, when people always are talking about, “well, we shouldn't really have diversity and inclusion and it's political within medicine,” it's like, but it's not political. This is about our lives and our communities.

Dr. Blair Bigha...: Absolutely. That's it for this episode of the CMAJ Podcast. We'll see you in two weeks. Please be sure to share, or like this podcast, wherever it is that you download your audio. I'm Blair Bigham.

Dr. Mojola Omol...: I'm Mojola Omole. Until next time, be well.